Provider Demographics
NPI:1508931338
Name:PRUTZMAN & OSGOOD ORTHOPEDIC SURGEONS
Entity Type:Organization
Organization Name:PRUTZMAN & OSGOOD ORTHOPEDIC SURGEONS
Other - Org Name:ADVANCED ORTHOPEDICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:775-786-2100
Mailing Address - Street 1:689 SIERRA ROSE DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89511-2060
Mailing Address - Country:US
Mailing Address - Phone:775-786-2100
Mailing Address - Fax:775-786-7706
Practice Address - Street 1:689 SIERRA ROSE DR
Practice Address - Street 2:SUITE B
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89511-2060
Practice Address - Country:US
Practice Address - Phone:775-786-2100
Practice Address - Fax:775-786-7706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV207X00000X207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXPY190263Medicaid
CAXPY190263Medicaid